The consumption of pharmaceuticals has
increased over the past decade not only in terms of expenditure (see Indicator 5.5
"Pharmaceutical expenditure" ), but also in terms of the
volume or quantity of medicines consumed. This section reviews trends in the volume of
consumption of three categories of pharmaceuticals: antibiotics, antidiabetics and
antidepressants. Consumption of these medicines is measured through the defined daily dose
(DDD) unit, as recommended by the WHO Collaborating Center for Drug Statistics (see the
box on "Definition and comparability" ).

Antibiotics should not be used
needlessly, as there is a clear correlation between their use and the emergence of
resistant bacterial strains (Bronzwaer et al., 2002;
Goossens et al., 2005). As with any other prescribed
medicines, overprescribing exposes patients unnecessarily to risks of side-effects without
achieving more rapid recovery (Fahey et al., 2004).

The use of antibiotics varies across
European countries, ranging from 10 DDDs per 1 000 people per day in Latvia, the
Netherlands and Romania, to over 30 in Greece and Cyprus (Figure 3.11.1). Consumption has stabilised in several countries over the
past decade, and it has decreased in some countries including Estonia, France, Hungary,
Portugal and Slovenia. But antibiotic use has risen in other countries such as Belgium,
Greece and Italy which already had higher-than-average consumption in 2000, thereby
widening the gap with other European countries. One way of reducing unnecessary use is to
avoid prescribing them for mild and/or viral infections. Many countries have launched
information campaigns targeting physicians and patients to reduce consumption. At the
international level, WHO launched in 2011 a campaign to stimulate co-ordinated efforts to
promote appropriate and rational use of antibiotics (WHO, 2012b).

Clinical guidelines in different
European countries recommend the use of various medicines to treat people with diabetes to
reduce the risk of cardiovascular and microvascular complications (Beckman et al., 2002; UKPDS, 1998). There is wide variation in the use
of medicines for the treatment of diabetes across European countries, with consumption in
Iceland and Estonia almost half that in Finland or Germany (Figure 3.11.2). This can be partly explained by the prevalence of diabetes,
which is low in Iceland (see Indicator 1.10). However, some of the
countries with the highest consumption do not have high diabetes prevalence (e.g. Finland, Germany and the United Kingdom). Between 2000
and 2010, the consumption of antidiabetics increased by 75% on average across EU member
states. The growth rate was particularly strong in Finland, Germany and the Slovak
Republic. The main reasons for this strong rise are increases in the proportion of people
treated and the average dosages used in treatments (Melander et al., 2006).

Guidelines for the pharmaceutical
treatment of depression vary across countries, and there is also great variation in
prescribing behaviors among general practitioners and psychiatrists not only across
countries, but also among individual practitioners in each country. Iceland has the
highest level of consumption of antidepressants, followed by Denmark and Portugal (Figure 3.11.3). Part of the explanation for the high consumption in Iceland
is that a much higher proportion of the population receives at least one prescription for
an antidepressant each year. In 2008, almost 30% of women aged 65 and over had an
antidepressant prescription in Iceland, compared with less than 15% in Norway (NOMESCO,
2010). But the intensity and duration of treatments also play a role in explaining
variations across countries and trends over time. In all European countries for which data
is available, the consumption of antidepressants has increased a lot over the past decade,
by over 80% on average across EU member states. While some analysts interpret these
findings as evidence of a growing prevalence of depression, this also reflects greater
efforts to provide treatments to people suffering from severe depression and greater
intensity of these treatments. This rise can also be explained by the extension of the set
of indications of some antidepressants to milder forms of depression, generalised anxiety
disorders or social phobia, which have raised issues in some countries about the
appropriateness of such extensions of prescriptions.

Definition and comparability

Defined daily dose (DDD) is the
assumed average maintenance dose per day for a medicine used for its main indication
in adults. DDDs are assigned to each active ingredient(s) in a given therapeutic class
by international expert consensus. For instance, the DDD for oral aspirin equals
3 grams, which is the assumed maintenance daily dose to treat pain in adults. DDDs do
not necessarily reflect the average daily dose actually used in a given country. DDDs
can be aggregated within and across therapeutic classes of the Anatomic-Therapeutic
Classification (ATC). For more detail, see www.whocc.no/atcddd.

Data generally refer to outpatient
consumption except for the Czech Republic, Finland and Sweden, where data also include
hospital consumption. Greek figures may include parallel exports.